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Archived: Burgess Park Inadequate

The provider of this service changed - see old profile

The provider of this service changed - see new profile

We are carrying out a review of quality at Burgess Park. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 27 April 2017

Burgess Park is a nursing home that provides accommodation and personal care for up to 60 people, some of whom are frail and live with dementia. At the time of the inspection there were 31 people living at the service.

We carried out a comprehensive inspection at this service on 17 December 2015, and rated it as requires improvement. At that time we found two breaches in regulations for safe care and treatment and good governance. We asked the registered provider to send us a plan to tell us what they would do to meet legal requirements. We did not receive the action plan.

We carried out a focussed inspection on the 13 September 2016. We did not look at all of the Key Lines of Enquiry under each key question. We followed up on the breaches of regulations to see if the registered provider had made improvements to the service. At the last inspection on December 2015 we asked the provider to take action to make improvements for safe care and treatment and good governance. We found for safe care and treatment this action has been completed. However, we found the provider was in continued breach of good governance. We also found new breaches of staffing and person centred care. The provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. You can read the report from our last inspection, by selecting the 'all reports' link for Burgess Park on our website at

This comprehensive inspection was carried out on 23 and 31 January 2017 to check that the registered provider had followed their plan and to check that they now met the regulations inspected. During this inspection, we found evidence that the provider had made some improvements. We found that the breach in relation to staffing was now met. We found a continued breach of good governance. We also found new breaches of safe care and treatment and need for consent. We found that further action is required to meet all the regulations we inspected.

There was no registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered provider was recruiting for a home manager. There is an interim manager at Burgess Park supporting the service whilst a permanent manager is recruited.

People did not receive safe care and treatment that met their needs because staff had not acted to manage them. People's health conditions were not managed well and they were at risk from deterioration of their health. Staff had not always followed health care professional’s advice and recommendations to manage people’s health needs effectively.

People did not have their medicines provided to them in a safe way. We found examples where staff did not administer medicines to people a way that helped maintain their health.

The quality assurance systems in place did not identify the areas of concern we found. The provider’s governance systems and audit systems were not always well organised. People did not receive safe quality care because the governance systems did not identify any concerns with the service.

People and their relatives, gave feedback to the provider about the quality of care they received. However, we found that the quality of care experienced did not match our findings at the inspection.

Assessment identified people’s care and support needs. These were completed with people and their relative. A plan of care was developed in order to provide guidance for staff to meet those assessed needs. However we found that reassessments of people’s needs did not take into consideration new health needs. Risks to people’s health and well-being were not always identified and used to plan their care.

Activities for people did not alway

Inspection areas



Updated 27 April 2017

Risk assessments and management plans were in place for people. However staff had not always followed guidance to manage the recurrence of risks.

People�s medicines were not administered to ensure people received them safely.

There were sufficient numbers of staff to provided care and support to people.

Safeguarding processes were in place to protect people from harm and abuse.


Requires improvement

Updated 27 April 2017

People had access to health care services when required. However staff did not always follow professional recommendations and guidance.

People were not always supported to consent to care and support. Staff did not always have an awareness of supporting in line with the principles of the Mental Capacity Act 2005 (MCA) to keep them safe.

Meals were provided to meet people�s needs and preferences.


Requires improvement

Updated 27 April 2017

Activities for people did not meet their preferences or needs. Staff knew people well and understood their preferences and wishes. People were not always treated with dignity.


Requires improvement

Updated 27 April 2017

The service was not always responsive. People did not have activities that net their needs and preferences.

The registered manager had a complaint system in place for people to make a complaint about the service.



Updated 27 April 2017

The service was not well led. The service undertook regular quality audits but these did not identify and act on the concerns we found.

The service was managed by an interim manager with the support of other provider�s managers. People were unclear of who was managing the service.

Staff told us that the manager listened to their concerns and acted on them as able.